Hepatitis C virus (HCV) infection is a chronic disease which, despite its initial asymptomatic course, affects several aspects of patient well-being, including physical, mental, social and sexual quality of life. , even in the early stages of the disease.
Sexual health issues will be associated with HCV in several ways:
First, sexual behaviors and practices may be linked to an increased risk of HCV infection. Indeed, even if hepatitis C is not considered to be a sexually transmitted infection, since it is essentially transmitted during blood exchanges, transmission during sexual intercourse can still take place in the event of menstruation, intercourse unprotected anal sex or practices qualified as “hard”.
Second, HCV infection can lead to sexual dysfunction in its own right. Researchers have identified three distinct types of sexual disorders depending on the stage of the disease :
- pre-cirrhotic sexual disorders, at the very beginning of the disease
- sexual decline induced by cirrhosis, when the disease is advanced
- and sexual difficulties associated with interferons, which is an old treatment for hepatitis C
Unfortunately, these clinically significant and long-lasting disturbances, which disrupt the daily lives of patients, most often escape the attention of clinicians.
Studies highlight sexual difficulties in patients with hepatitis C virus (HCV) at frequencies ranging from 19% to 88% depending on the study.
Those reporting relatively low percentages of sexual dysfunction, (19.4 to 22.2%), either excluded other comorbidities, such as diabetes mellitus, or their samples are relatively young or include patients with early stages of fibrosis.
Conversely, those including cirrhotic patients of advanced age show that the vast majority (88%) present sexual dysfunctions.
Different types of sexual disorders
HCV infection is linked to sexual difficulties primarily in the areas of sexual desire, drive and satisfaction.
Studies also show a significant association between erectile dysfunction and history of HCV infection..
Additionally, untreated HCV patients often have lower total and free testosterone levels, a risk factor for erectile dysfunction..
Finally, only an extremely small percentage (7.7%) of HCV patients complained of a complete loss of interest in sex..
Correlation between sexual disorders and disease stage
1- Pre-cirrhotic sexual disorders
At the very beginning of the disease, before the virus could damage the liver and cause what is called cirrhosis, the most frequently observed sexual disorders are disorders of desire (low libido) and satisfaction. sexual .
These difficulties may be explained by extra-hepatic pathophysiological processes and increased psychological distress.
Indeed, the fact that patients with hepatitis C report greater impairment of those aspects of sexuality that are based on higher cortical processes, compared to other sexual subdomains, such as erection, ejaculation or orgasm, which rely primarily on reflexes, could suggest disturbances in the neural circuitry of the prefrontal cortex, limbic system, hypothalamus, and ventral striatum, either from the direct effects of the virus or from cause of HCV-induced neuroinflammation.
2- Sexual disorders induced by cirrhosis
Cirrhosis-induced sexual decline appears to be related to liver fibrosis stage only in elderly patients and in patients with advanced cirrhosis, whereas in younger patients and those with milder liver disease, disease severity does not determine their sexual well-being.
Cirrhosis is often accompanied by altered sex hormone levels due to metabolic dysfunction, altered concentration of sex hormone binding globulin, impaired physical health, or adverse effects. side effects of drugs, which may explain why this stage will be more deleterious for people of advanced age.
3- Sexual difficulties associated with interferons
Today, the reference treatment for hepatitis C is based on direct-acting antivirals (DAAs). These new drugs treat all forms of hepatitis C and their side effects are mild.
But for years, treatment was based on interferon (INF), a protein that interferes with viral replication and stimulates immune cell activation. And this is unfortunately still the case in countries that cannot afford the exorbitant price of DAAs.
IFN is associated with a variety of symptoms including malaise, fatigue, cognitive impairment and depression.
Sexual difficulties associated with IFN therapy are therefore related to the combined effect of depression and viral pathophysiology.
During IFN therapy, patients with HCV experience a significant decline in all aspects of sexual functioning.
All studies agree that this initial decline is followed by a gradual improvement after the end of treatment, which is most evident in patients who achieve a sustained virologic response. .
On the other hand, relapsers who continue to receive IFN maintenance treatment for a long period show greater sexual difficulties than untreated relapsers, which raises serious doubts about the efficacy and safety of IFN treatment. long term to IFN for this group of patients.
The fact that virological responders report better sexual health after treatment, while for non-responders, IFN is associated with persistent sexual difficulties after treatment, indirectly suggests that HCV-associated sexual impairment is at least in partly a consequence of the virus itself and could be a possible target for new direct-acting antiviral agents.
When comorbidities weigh on sexual dysfunction
The pathogenesis of HCV-related sexual dysfunction is multifactorial, encompassing both physical and psychological subcomponents.
Most studies establish a strong correlation between sexual dysfunction and poor quality of life, especially in the physical and social domain, highlighting the crucial role of standard sexual health assessment in daily clinical practice..
Age, sex and unemployment rate are indeed strongly associated with the sexual functioning of patients with chronic hepatitis C.
In addition, depressive symptoms are strongly associated with impaired sexual functioning and increase the risk of IFN-associated sexual dysfunctions..
Finally, in addition to the duration of treatment, other parameters have appeared as determinants of sexual dysfunctions associated with IFN: advanced age, advanced fibrosis, poor basic physical functioning, history of hypertension, rates of high cholesterol and the use of antidepressants.
Several questions still deserve rigorous, large-scale investigations, including the sexual functioning of women with hepatitis C, and the impact of new treatments on sexual health and overall quality of life.
Furthermore, human sexuality is a vast phenomenon with multiple dimensions and implications, the assessment of which, whether in research or in a clinical context, requires time, sensitivity, expertise, excellent communication skills and the ability to create an atmosphere that is both professional and at the same time comfortable and discreet.
Several studies show that physicians focus on different areas of interest in relation to HCV patients and are sometimes perceived as inattentive to patients’ subjective needs.
We therefore strongly believe that when assessing sexual health issues, researchers should not rely exclusively on self-report questionnaires and psychometric scales, but also incorporate semi-clinical clinical interviews. structured or even unstructured, allowing participants to communicate a wide range of their subjective experiences.
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Impact of hepatitis C on sexuality
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